Inspection on 06/02/06 for St Catherine`s House Nursing Home

This inspection was carried out on 6th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Catherine`s House Nursing Home 10/07/06

St Catherine`s House Nursing Home 06/06/05

St Catherine`s House Nursing Home 07/02/05

St Catherine`s House Nursing Home 05/07/04

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Ashlong House

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

The Royal Star and Garter Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Catherine`s House Nursing Home 23a Kensington Square London W8 5HN Lead Inspector Sheila Lycholit Unannounced Inspection 6th February 2006 10:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Catherine`s House Nursing Home Address 23a Kensington Square London W8 5HN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7937 9688 020 7361 4757 The Trustees of the Congregation of the Religious of the Assumption Mrs Patricia Southern Care Home 14 Category(ies) of Physical disability (14) registration, with number of places St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2005 Brief Description of the Service: St Catherines House is a 14 place Care Home with Nursing, which provides care and support for older sisters of the Order of the Religious Assumption in a setting where they can continue to be part of the religious community. On occasions lay people needing care may be admitted. The accommodation is in a modern, well-adapted building over 3 floors. It overlooks a large garden square shared with other services on the Maria Assumpta site. The home also has its own private garden. All bedrooms are single rooms with en suite facilities. The building has a lift and is accessible for wheel chair use. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit took place on Monday 6th February 2006 from 10.40AM until 2.45PM. The Manager was on duty and made herself available throughout the visit. There were 9 residents at St Catherine’s, 8 of whom were Sisters and 1 a lay person. The Inspector spoke with 2 members of staff in private and met with residents during a tour of the building. The Inspector also spoke with the Provincial Superior who has overall responsibility for the home on behalf of the Order and the new Community Superior. The visit included a tour of the building. The Manager had completed a pre-inspection questionnaire in November 2005. Comment cards were received from 3 relatives and 4 health care professionals. All of the feedback received was positive, both about the way the home was managed and about the care of residents. What the service does well: What has improved since the last inspection? What they could do better: The Trustees must ensure that monthly visits on behalf of the provider take place and that reports of the visits are made in accordance with Regulation 26. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4 Clear information about the service is provided, although Sisters considering a move to St Catherine’s House are normally very familiar with the home, having lived in the adjacent main house. An established assessment procedure is in place and the staff team has good access to advice from the community multi-professional team. EVIDENCE: Copies of the Statement of Purpose, Service Users Guide and complaints procedure are available in the home, together with a copy of inspection reports. The files of the 3 residents with the highest needs were looked at. Each contained an up to date assessment, from which a care plan had been developed. No new residents have been admitted since the previous inspection in June 2005. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Care plans, including risk assessments, are of a high standard. Staff ensure that residents have access to a range of health care services. The Manager regularly monitors the administration of medication to ensure that good practice is promoted. Sisters of the Order and senior staff promote an atmosphere of respect and concern for residents. EVIDENCE: Each of the 3 personal files seen was in good order. Information is easy to find as each file has a contents sheet and is sub-divided. The Manager has reviewed all care plans, including risk assessments. Care plans are comprehensive, covering 12 areas of activities of daily living. They are regularly reviewed and updated. Residents daily notes are cross-referenced to the core care plan. Discussion with the Manager and feedback from health care professionals show that prompt referrals regarding health concerns are made and advice sought. The GP from the local Health Centre visits monthly and more often if required. The multi-professional notes on residents’ files show that there is multi-disciplinary approach. Feedback from health care colleagues commented St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 10 on the high standards at St Catherine’s, the receptiveness of staff to suggestions and their active participation in training. The home uses a pre-measured dosage system of medication. Staff regularly up date their training in the administration of medication. MAR sheets were looked at and were up to date and fully completed. The Manager carries out a regular audit of medication, noting any errors. A system is in place for assessing and monitoring those residents who manage their own medication. Medication is stored in a locked room. The home has an established ethos of treating residents with dignity, respect and of meeting their spiritual needs. Staff were observed to support residents with personal care in a discreet manner. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents are supported to continue to follow the religious life that they have chosen, attending Mass, prayers and community meals and meetings wherever possible. Families and friends visit regularly and good links are maintained with the community. Steps have been taken to ensure that the meals fully meet the nutritional needs of the frailest residents. EVIDENCE: A schedule of each resident’s daily routine was seen on individual files. Daily routines are drawn up with each resident and amended to reflect changes in a resident’s condition. With the exception of the resident who is not a member of the order, Sisters’ daily routines centre around the religious community, with regular attendance at Mass and prayers, though these routines are altered for the most frail residents. Families and friends visit regularly and accommodation is available for overnight stays. The home operates as part of the community on the Maria Assumpta site. There are also long established links in the local area. Feedback was received from 3 relatives, all of whom commented positively on the care provided at St Catherine’s. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 12 Meals are normally taken in the dining room, where Sisters are cared for by other members of the Order. The non-religious resident has her meals in the first floor sitting room. Catering is provided by an external contractor. The Manager has reviewed menus with the Chef, in particular supper menus, to ensure that the dietary needs of residents whose food intake is small are fully met, for example by including more milk based dishes and seasonal vegetables. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 There is a clear complaints policy, which has been recently revised. Systems are in place to protect residents and to promote their welfare. EVIDENCE: The complaints procedure has been revised by the Manager. A new staff handbook was issued in 2005, that included policies on whistle-blowing and bullying. Staff have received training in the protection of vulnerable adults. An anonymous complaint was received by CSCI in November 2005, which was investigated by the Inspector and was not substantiated. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The service is provided in an attractive and well-adapted building. The building and pleasant gardens are fully accessible for wheelchair users. Systems are in place to identify the need for specialist equipment. Steps are taken to ensure the health and safety of residents and staff. EVIDENCE: All bedrooms are single rooms with an en suite lavatory and washbasin. Bedrooms have views over the gardens and are light and airy. There are a number of communal areas, suitably furnished and designed for the needs of residents. There are sufficient bathrooms and lavatories throughout the building, including a walk-in shower. A new mobile hoist has been purchased since the last inspection. On the day of the unannounced inspection the building was clean and tidy. As usual the garden provided pleasure to residents, as it is designed to be St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 15 enjoyed both from inside the building and outside in all seasons. A selection of potted spring bulbs were placed throughout the home. A contractor was present investigating problems with the hot water valves. Hot water temperatures are regularly taken. The schedule of service visits shows that the water quality is tested twice a year. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staffing levels meet the needs of the current residents. Sound procedures are in place to ensure that suitable staff are appointed. Staff training and development is given a high priority. EVIDENCE: Staff rotas show that 1 RGN and 1 Health Care Assistant are on duty on each shift, including at night. The Manager and senior members of the Order are available for advice out of hours. Staffing levels are sufficient for the needs of the current residents. Of the 9 residents, 3 have high needs, while others need varying degrees of support and assistance. An established programme of NVQ training is provided, although staff turnover has meant that just under 50 of Care Assistants have achieved NVQ2. The personnel files of the 2 most recently recruited staff were looked at. These showed that good practice had been followed in all aspects of their recruitment and appointment. The Manager ensures that evidence of the CRB check and PIN number, where applicable, are obtained for any agency staff before they work at the home. Staff undertake a probationary period. An excellent staff training and development plan is available, based on an analysis of the needs of the service. Staff have access to a range of training , including NVQ, external and in house workshops. The Manager has a supply of videos and reading material on aspects of the care of older people that is available to staff. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 17 The 2 most recently appointed staff confirmed that they had completed or were undergoing a sound induction to working at the home. The Manager has designed an induction checklist for new staff. All staff have undertaken basic health and safety training, including refresher training. Training in First Aid was planned for the following week. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 The home is currently well managed, however the imminent departure of the Manager after less than 8 months means that the Trustees have not achieved continuity of management. The Trustees have not assured themselves about the welfare of the residents and operation of the home by monthly visits, which are recorded. Record keeping is generally of a high standard and systems are in place to ensure the health and safety of residents and staff. EVIDENCE: The Manager, who is experienced and well qualified, has introduced a number of beneficial changes to the home, including revising policies and procedures, devising a staff development plan based on organisational objectives, improving record keeping and taking steps to ensure that care plans are fully implemented. Staff commented on the support that they received from the Manager and her availability for advice and guidance. Staff meetings take place approximately every 2 months. In addition there is a regular meeting for RGNs. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 19 At the time of the unannounced visit, the Manager was working out her period of notice. The Provincial Superior and Community Superior were interviewing 3 agency staff that day to cover the Manager’s post on an interim basis. The Provincial Superior was later able to inform the Inspector that a temporary appointment had been made from the candidates. The Manager attends the monthly Trustees meeting, presenting a report on the service. Lines of accountability regarding the responsibilities of the Registered Manager and senior members of the Order have been agreed and are documented, though have not always been followed. While the Provincial Superior who is based on the Maria Assumpta site visits the home often, no reports of her visits are available as required under Regulation 26. In discussion the Provincial Superior undertook to ensure that this requirement would be met. The Bursar manages the finances of members of the Order. One resident’s finances are managed by her next of kin. A system of staff supervision is in place. The supervision records of 1 member of staff were seen, which showed that supervision had taken place regularly and had been recorded using a pro forma. Records are kept in good order. A mix of computerised and handwritten recording is used. As noted above, all staff receive training in health and safety, as part of induction and as refresher training. A schedule of maintenance and servicing is available, showing that equipment and systems are regularly checked. Security to the building was increased last year with the introduction of an entry phone at the main door, which is kept locked from the outside. Accidents are carefully recorded and residents’ files show that risk assessments are reviewed following an accident, with any identified action taken. The Manager and the PCT Consultant Nurse for Older People are monitoring falls as part of a falls prevention initiative. Fire records were not readily available on the day of the inspection but were sent to the Inspector the following day. These showed that 6 fire drills had taken place since the last inspection, including a practice for night staff. The Inspector visited the kitchen with the Manager. The Chef was off duty. The kitchen was clean and tidy. Records showed that fridge and freezer temperatures had been taken daily. An EHO visit took place on 28th September 2005. There was only one requirement, which related to the labelling of frozen food. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 x 3 3 3 3 St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 33 Regulation 26 Requirement Monthly visits on behalf of the Trustees must take place and be recorded. Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP37 OP38 OP38 Good Practice Recommendations Ways of supporting care staff to contribute to care planning and recording should be explored. Any bin used to dispose of food eg. in the kitchenettes, should have a lid. All hand-washing areas used by staff should have disposable towels/hand-driers to prevent cross infection. St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Catherine`s House Nursing Home DS0000026017.V278569.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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